PROVAIL Therapy Services Application
|
|
- Adela Woods
- 8 years ago
- Views:
Transcription
1 PROVAIL Therapy Services Application
2 PROVAIL Therapy Services Application
3 PROVAIL Therapy Services Application
4 PROVAIL Therapy Services Application
5 PROVAIL Therapy Services Application
6 PROVAIL Availability/ Insurance Verification Worksheet Thank you for choosing PROVAIL for your Speech or Occupational Therapy. Once we have received the completed new intake packet you will be added to the waitlist. A physician referral will also be required before scheduling any therapy services. Knowing your availability will help us know to contact you when a session becomes available. Knowing your insurance coverage will help you understand your family cost participation for this therapy. Please provide a front and back copy of all medical insurance cards. Client Name: Client DOB: Name of Parent/Guardian/POA: Phone Number: Availability What days and times of the day would work best for therapy (circle all that apply)? Monday Tuesday Wednesday Thursday Friday 8 10 am 10 noon Noon 2pm 2pm 5pm Please complete all forms and return to: PROVAIL Aurora Ave North Seattle, WA (clinic) (fax) I understand and accept my responsibility to pay any remaining balance, including deductible and co payments, required under my insurance plan. Signature Date 1 PROVAIL Therapy Services Application
7 Insurance Information: Please phone your Insurance Company and fill out this form the best you can. This is very helpful information if you are unfamiliar with your coverage. Name of your Insurance: Insurance Phone Number: Policy Holder s Name: Effective Date of Policy: ID #: Plan/Group #: When you call be sure to write down the name of the person that you talk to for later reference. Contact Person: Date, Time of call: Say, I m calling to clarify my benefits and coverage for neurodevelopmental outpatient services. If your Insurance provider states you do not have coverage under this benefit ask them to clarify benefits for Speech and/or Occupational Therapy. Other helpful information: PROVAIL Tax ID#: PROVAIL s National Provider Identification # (NPI): Questions to ask: Is PROVAIL, on the Participating Provider List? Yes No If PROVAIL is NOT in your network, then ask these questions: o Does my policy allow me to choose my own therapist? Yes No o Can I go outside of my network or the provider list? Yes No If yes, what is the difference/cost? Do I need a Letter of Medical Necessity from a Primary Care Doctor to access outpatient neurodevelopmental services or Speech and/or Occupational Therapy? Yes No Is Pre authorization from my insurance company needed for outpatient neurodevelopmental services or Speech and/or Occupational Therapy? Yes No If yes, how is it submitted? Then ask: What is my Co pay % or $ /session. Is the co pay or coinsurance per day or per therapy? (For example, if your child sees an OT and Speech pathologist and you have a $15 copay, do you owe $15 per therapy which totals $30 or only $15 per day? Do I have a deductible? Yes No What is the amount of my Deductible $ / family or individual? 2 PROVAIL Therapy Services Application
8 Has my deductible been met for this year? Yes No How much have I paid towards my deductible? What are the dates for my benefit year? to What is my maximum out of pocket expense for the year? What is my benefit maximum? How may visits are allowed per year, per therapy? visits for OT, visits for ST Have any of my benefits been used to date? Yes No If yes, please explain: Are the following CPT codes covered? Therapy Code Yes No Speech Therapy (ST) 92523, 92507, 92508, 92607, 92609, 92608, Occupational Therapy (OT) 97003, 97004, 97110, 97112, 97542, 97530, 97535, 97760, Disclaimer: The CPT codes on this form are subject to change based on your needs and services provided. Please ask your therapist if you have questions regarding the codes being used. Please be aware that the information obtained from your insurance company is not a guarantee of coverage/payment. Is there any plan exclusions for Self Care? Yes No If yes, please explain: ADDITIONAL TIPS 1. Keep a paper trail. Always make note of the date whenever you call your insurance, and have paper and pen ready to write down as much information as you can. If possible, get the first and last name of the insurance representative you are speaking with, along with a number/extension where that person can be reached and the name of that person s supervisor. 2. Remember that YOU are the customer! Don t feel rushed when talking to your insurance representative; they are there to serve you. Take your time asking questions and be sure you understand their answers before hanging up. 3. Keep copies of everything! Including copies of referrals from your PCP, copies of specialty evaluations, copies of anything sent to you from your insurance company even if your insurance covers at 100% 4. MONITOR your benefits! If you or your child is receiving ongoing services, call your insurance on a regular basis (ie: once a month) to get an update on the status of your benefits. If your benefits are running out, let your therapist know so options can be discussed. Referrals and authorization must be renewed on a regular basis, if you don t monitor this you may be responsible for the bill. 5. Tell us if your INSURANCE CHANGES!! Let PROVAIL know in advance of your next appointment if your insurance has changed. You will need to complete this worksheet again, and possibly get a new referral and/or authorization. 3 PROVAIL Therapy Services Application
9 Therapeutic and Assistive Technology Services LEGAL REPRESENTATION Client Name: Do you (client) have a guardian? No Do you (client) have a financial payee? No Your billing address: Yes Guardian Name: Yes Payee Name: Guardian Address: Payee Address: Guardian Phone: Payee Phone: Guardian Payee Aurora Ave. N. Seattle, WA Phone: Fax: frontoffice@provail.org PROVAIL Therapy Services Application
10 PROVAIL Therapy Services Application
11 PROVAIL Therapy Services Application
Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan
ConneCtiCut insurance DePARtMent Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan What consumers need to know about seeking approval for behavioral
More informationConsumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan
CONNECTICUT INSURANCE DEPARTMENT Consumer Toolkit for Navigating Behavioral Health and Substance Abuse Care Through Your Health Insurance Plan What consumers need to know about seeking approval for behavioral
More informationPatient Information. Claims Address: Please also provide Health Insurance information in addition to Work Comp /Auto
For Office Use Updated By (Initial Here): Mailing Address: Patient Information City, State & Zip: Primary Home Cell Permission to Leave Messages: Yes No Secondary Home Cell Permission to Leave Messages:
More informationPATIENT FINANCIAL POLICIES Effective Date: June 1, 2015
Cardiovascular Specialists of Central Maryland A Community Specialty Practice of Johns Hopkins Medicine 10710 Charter Drive, Suite 400 Columbia MD 21044 PATIENT FINANCIAL POLICIES Effective Date: June
More informationPATIENT INFORMATION. Patient: S.S.# Address: D.O.B. Home Phone: Bus Phone: Male Female. Emergency contact: Relation to Patient: PH#
Massage 258 West 91 st Street, Suite 1-B Physical THERAPY EXPERTS, PLLC WELCOME 212-875-8345 T PLEASE FILL IN FORM COMPLETELY TO AVOID INSURANCE PAYMENT DELAY! PATIENT INFORMATION Patient: S.S.# Address:
More informationPATIENT INFORMATION EMERGENCY CONTACT LAST FIRST RELATIONSHIP REFERRAL SOURCE DOCTOR / REFERRING CLINICIAN: FAMILY MEMBER/FRIEND: INSURANCE:
PATIENT INFORMATION LAST FIRST MI GENDER M F BIRTHDATE MO./ DAY/ YEAR SS# - - ADDRESS CITY ST ZIP PHONE (CELL) PHONE (HOME) EMAIL MARITAL STATUS EMPLOYER ADDRESS OCCUPATION WORK PHONE EXT WHO IS YOUR PRIMARY
More informationPRE-SCREENING CHECKLIST
PRE-SCREENING CHECKLIST Please provide the following information and mail, email or fax to: Positive Synergy Corp. 45 Spring Hill Ave. Northbridge, MA 01534 Email: intake@positivesynergyasd.org Fax: (508)-401-2696
More informationPhysical Occupational and Speech Therapy Patient Information Sheet
Physical Occupational and Speech Therapy Patient Information Sheet FIRST NAME: MI: LAST NAME: ADDRESS: HOME PHONE: WORK PHONE: MALE FEMALE CELLPHONE: DOB: SS# EMERGENCY CONTACT: PHONE: RELATIONSHIP: PRIMARY
More informationIf you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.
Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical
More informationUNDERSTANDING YOUR MEDICAL BILL. Thank you for choosing Your Personal Physicians at:
UNDERSTANDING YOUR MEDICAL BILL Thank you for choosing Your Personal Physicians at: Mercy Medical Center Lutherville Overlea Worthington/Reisterstown Glen Burnie Canton as your healthcare provider. We
More informationJane Beresford, Psy.D. Licensed Psychologist PSY 16618 (310) 551-8535 Info@DrBeresford.com 15300 Ventura Boulevard, Suite 301
Patient Information (PLEASE PRINT) Patient Name: _ Today s Date: Patient s SSN: - - DOB: / / Age: Sex: Marital Status (circle): Single Married Separated Divorced Other: Home Address: Email: OK to leave
More informationLife Tide Counseling, PC Individual, Marriage and Family Counseling
Life Tide Counseling, PC Individual, Marriage and Family Counseling OUTPATIENT SERVICES CONTRACT Therapist: ( Therapist ) Client: ( Client ) Welcome to Life Tide Counseling, PC ( Life Tide Counseling ).
More informationGuide to Purchasing Health Insurance
Guide to Purchasing Health Insurance What are your health insurance choices? Which type is right for you? Sample questions Looking for insurance in specific situations Tips for shopping for health coverage
More informationGoals. Reflection. The 3 Ps: Marcus Lemonis. Private Practice Management: From Intake to Billing 9/1/15
Private Practice Management: From Intake to Billing Christian J. Dean, Ph.D., LPC-S, LMFT, NCC And Sola Kippers, Ph.D., LPC-S, LMFT, CRC, CCTP Goals O Have an understanding of overall practice components
More informationWelcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our facility.
AVIDAPT 1391 Dublin Rd, Columbus, OH 43215 614-487-9715 avidapt.com Welcome to Avida PT. The purpose of this letter is to provide you with some helpful information to prepare you for your visits to our
More informationTribute Health Plan of Arkansas (HMO SNP), a Superior Select product.
Tribute Health Plan of Arkansas (HMO SNP), a Superior Select product. Tribute Health Plan of Arkansas HMO SNP is a Health plan with a Medicare contract. Enrollment in Tribute Health Plan of Arkansas HMO
More informationUnderstanding Your Medical Bill
Understanding Your Medical Bill THANK YOU for choosing University of Maryland Medical Center (UMMC) as your healthcare provider. We are committed to providing excellence in the delivery of healthcare.
More informationHow To Help A Child With A Disability
Five Counties Children's Centre is dedicated to supporting children and youth with physical, developmental and communication needs and their families. In partnership with families and communities we strive
More informationWarner Family Counseling
Warner Family Counseling General Policies Insurance: I will file claims on your behalf, provided that I am an in-network contracted provider with your individual plan. Prior to our first meeting contact
More informationUPDATE FORM 2011. Name: (First) (Last) (Middle Initial) Address: Home Phone: Work/Other Phone. Social Security #: Date of Birth:
COMPREHENSIVE PSYCHIATRIC CARE Psychopharmacology & Psychotherapy Adults, Adolescents, Children & Seniors UPDATE FORM 2011 Please fill out this form completely (front and back) Name: (First) (Last) (Middle
More informationNew Patient Intake Package
CORE Physical Therapy 1255 S State St, Suite 7 Dover, DE 19901-6932 Phone: (302) 734-0100 Fax: (302) 734-0101 New Patient Intake Package - Welcome Letter - Consent Form - Appointment Contact Preference
More informationOccupational Health Services
Occupational Health Services Workers Compensation MCO Occupational Health Services Workers Compensation MCO This section of the Provider Manual was created to provide you and your staff with basic organizational
More informationCommunity Mental Health Resources
Community Mental Health Resources IF YOU OR A FRIEND HAS THOUGHTS OF SUICIDE OR HARMING YOURSELF OR SOMEONE ELSE: *Call 911 or *Go to the Emergency Department at Providence St. Peter Hosipital: 413 Lilly
More informationADULT REGISTRATION FORM. Last Name First Name Middle Initial. Date of Birth Age Identified Gender. Street Address. City State Zip Code
ADULT REGISTRATION FORM Last Name First Name Middle Initial Date of Birth Age Identified Gender Street Address City State Zip Code Home Phone Cell Phone FINANCIALLY RESPONSIBLE PARTY (If different from
More information2016 Boca Raton Fall Aquatic Descriptions. Due: January 6th, 2016 with $35.00 registration fee. Phone: 561-376-2573 Fax: 561-218-4939
2016 Boca Raton Fall Aquatic Descriptions Due: January 6th, 2016 with $35.00 registration fee Phone: 561-376-2573 Fax: 561-218-4939 Email: scheduling@ppt4kids.com Aquatic Therapy Exercise in the water
More informationRETINA CONSULTANTS OF HOUSTON. Date of Birth: Age: Sex: M F Martial Status: S M W D. Name of Spouse: Emergency Contact Name: Number:
RETINA CONSULTANTS OF HOUSTON 6560 FANNIN, SUITE 750, HOUSTON TX 77030 PATIENT INFORMATION Patient's Legal Name: Date of Today's Visit: Social Security # Date of Birth: Age: Sex: M F Martial Status: S
More informationIntake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:
Intake for Services Today's Date Last name: First name: Birth date: Age: Gender: Address: City/State/Zip Email: Home Phone: Cell phone: Marital Status: No. of Children & ages: If presently married: Name
More informationCalifornia Pain Consultants - PATIENT REGISTRATION FORM
Patient Information California Pain Consultants - PATIENT REGISTRATION FORM First name: Last name: Middle Initial: Address: City, State, Zip Home phone :( ) -Work phone: ( ) -_Cell: ( ) - Birth Date: Age:
More informationWhen you arrive for your first appointment, please bring the following with you:
115 N. Sumter Street, Suite 400, Sumter, SC 29150 Phone (803) 774-7425 (SICK) / Fax (803) 774-9426 www.cfmsumter.com WELCOME We are honored that you have chosen Carolina Family Medicine of Sumter for your
More informationbenefit summary BAXTER COUNTY
benefit summary BAXTER COUNTY benefit summary Effective Date: BAXTER COUNTY 01/01/2015 welcome Arkansas Blue Cross and Blue Shield is pleased to be your health insurance company. This Benefit Summary gives
More informationWelcome to Thomaston Savings Bank
Welcome to Thomaston Savings Bank Thank you for considering Thomaston Savings Bank for your banking needs. Since 1874, we have been dedicated to providing quality products and exceptional service to our
More informationClear Creek Amana Community School District
Clear Creek Amana Community School District Clear Creek Amana CSD Plan Comparison Plan Design Purchasing Plan Buy Down Option 1: Wellmark Alliance Select Wellmark Alliance Select Buy Down Option 2: Wellmark
More informationREHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)
CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over) Rehab Resources, Inc. is a certified agency that provides outpatient therapy services. Occupational, Physical,
More informationPatient Billing. Questions/ Answers. Assistance Programs
Patient Billing Questions/ Answers Assistance Programs Table of Contents Patient billing: an introduction... 1 Patient financial responsibilities... 2 Our promise to you... 3 Frequently asked questions...
More informationMental Health & Substance Abuse Services
Mental Health & Substance Abuse Services Services Overview The Adult Behavioral Health (ABH) Department provides Mental Health and Substance Abuse services to clients who meet criteria for either Substance
More informationPROTOCOLS FOR OCCUPATIONAL THERAPY PROVIDERS
PROTOCOLS FOR OCCUPATIONAL THERAPY PROVIDERS Type of Services Provided Services provided by Occupational Therapy providers are covered for Santa Barbara Health Initiative (SBHI), San Luis Obispo Health
More informationTHINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:
THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age: Social Security Number: Employment Status: Marital Status: Emp Unemp
More informationWORKERS COMPENSATION INFORMATION. Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone:
WORKERS COMPENSATION INFORMATION PATIENT INFORMATION Name: Birthdate: Soc. Sec.# Address Marital Status: Single Married Divorced Widowed Email: Home Phone: Cell Phone: Work Phone: Preferred Pharmacy: Tel
More informationBlueCHiP for Medicare 2016 Plan Selection Form
2016 Plan Selection Form Date: c c / c c / c c c c Instructions: Complete the following sections 1. Provide Demographics 2. Choose your Medical Plan 3. Choose your Optional Supplemental Dental Plan 4.
More informationGrapevine Behavioral Healthcare Associates 2311 Mustang Dr #300, Grapevine, TX 76051 Office (817) 481-7474 Fax (817) 416-0900
PATIENT INFORMATION Parent/Guardian Name (if patient is child/adolescent): Last Name: First Name: Middle: Social Security #: of Birth: Gender (please circle): Male Female Street Address: City, State, Zip
More informationTransitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047
Transitions Counseling Growing Towards Change 8641 5 th Street, Suite W-6 Frisco, Texas 75034 Phone: 972-369-9462 Fax: 972-636-8047 Insurance Information Sheet It is important that you thoroughly complete
More informationPiedmont Psychiatric Services
Piedmont Psychiatric Services 2094 Woodruff Rd. Greenville, SC 29607 Tony R. Goodbar, MD Jeffrey K. Smith, MD Joseph A. Friddle, PA-C James M. Harbin, M.Ed., LPC Michael D. Smith, MA, LPC Albert C. Bennett,
More informationWelcome! We look forward to serving YOU. If we can do anything to make your time with us more enjoyable, please let us know.
Welcome! We want to thank you for allowing us the opportunity to provide you with the highest level of quality rehabilitation services possible. We are committed to providing you with a comfortable, friendly
More informationPATIENT /GUARDIAN SIGNATURE
PATIENT INFORMATION EMAIL ADDRESS: First Name: Last Name: Middle Initial: Date: / / Address: City: State: Zip: Birth date: / / Age: Male Female S.S. #: - - Home Phone: ( ) - Alternative Phone (Cell, Pager):
More informationApplication for Services Checklist
Application for Services Checklist This form is not required, but rather is meant to help families gather all required information and documentation required to start ABA services at Behavior Analysts
More informationChoosing Health Care Insurance Medicare Supplements
Choosing Health Care Insurance By Steve Meinhardt http://yumainsurancehealth.com Office: 928-217-3621 Mobile: 928-580-7102 Fax No: 928-344-3507 Email: steve@yumainsurancehealth.com Or - Fill out the contact
More informationPatient Financial Policy
Patient Financial Policy We want you to concentrate on feeling better instead of worrying about how you're going to pay your bill. Please review this Patient Financial Policy for answers to commonly asked
More informationTo apply for the Colorado HIBI program, fill out the attached application and either fax or mail it with a:
Dear Applicant, The Colorado Health Insurance Buy-In (HIBI) program may reimburse health insurance premiums, copays, deductibles and coinsurance for a Medicaid client if the health insurance plan is cost-effective
More informationPATIENT REGISTRATION Date:
PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN
More informationChoosing the Right Health Insurance Plan What is the different between PPO, HMO, POS and HSA plans?
Choosing the Right Health Insurance Plan What is the different between PPO, HMO, POS and HSA plans? Choosing the right health insurance plan can be confusing. When open enrollment rolls around at your
More informationRenee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187
Renee Bellis, PsyD, CSAC Clinical Psychologist & Certified Substance Abuse Counselor 850 West Hind Dr. Suite # 110 Honolulu, HI 96821 P(808) 781-8187 F(808) 748-0778 OUTPATIENT SERVICES CONTRACT This document
More informationThe Healthy Mind PSYCHIATRIC SERVICES
The Healthy Mind PSYCHIATRIC SERVICES 900 Straits Tpk Suite D Middlebury, CT 06762 New Patient Registration: Patient s First Name Last Name Patient s Telephone: Home Cell Email: Patient s Date of Birth:
More informationHEALTH INSURANCE FOR INDIVIDUALS AND FAMILIES. Insuring Minnesota One Life At A Time. www.preferredone.com
foreveryone HEALTH INSURANCE FOR INDIVIDUALS AND FAMILIES Insuring Minnesota One Life At A Time www.preferredone.com for EveryOne Insuring Minnesota One Life At A Time Thank you for your interest in the
More informationEarly Intervention Central Billing Office. Provider Insurance Billing Procedures
Early Intervention Central Billing Office Provider Insurance Billing Procedures May 2013 Provider Insurance Billing Procedures Provider Registration Each provider choosing to opt out of billing for one,
More informationImportant Information About MassHealth Coverage Changes Effective January 1
Commonwealth of Massachusetts Executive Office of Health and Human Services Important Information About MassHealth Coverage Changes Effective January 1 January is a time of great change for healthcare
More informationUnderstanding Your Medical Bill
Understanding Your Medical Bill After you visit a provider, you ll typically receive a bill telling you how much you have to pay. Providers can include healthcare professionals, hospitals and other types
More informationTERM LIFE CHAMPIONS AN AGENT GUIDE
TERM LIFE CHAMPIONS AN AGENT GUIDE An Outline of the Sales Process and Miscellaneous Considerations Current statistics indicate that: 60% of the families earning between $50,000 and $250,000 each year
More informationCLINICS AND PROGRAMS PROVIDING REDUCED COST DENTAL CARE
Prepared by: Seattle-King County Dental Society 2201 Sixth Avenue, Suite 1210 Seattle, WA 98121-1857 206.443.7607 skcds@skcds.com www.skcds.org CLINICS AND PROGRAMS PROVIDING REDUCED COST DENTAL CARE Public
More informationSCHEDULE OF BENEFITS
SCHEDULE OF BENEFITS Premier HealthOne Bronze 5500 Health Maintenance Organization (HMO) Individual Certificate of Coverage This schedule of benefits (SOB) is part of your Certificate of Coverage (COC)
More informationVolunteer Application
Thank you for your interest in volunteer opportunities here at Magee Rehabilitation Hospital. To apply for volunteer placement, you will need to commit to volunteering a minimum of 100 hours and: 1) Complete
More informationSIMPLICITY. 2015 Your Plan Explained
Hello SIMPLICITY 2015 Your Plan Explained PFIZER UnitedHealthcare Group Medicare Advantage (PPO) Effective January 1, 2015, through December 31, 2015 Group Number: 12367, 12368 Benefit Highlights UnitedHealthcare
More informationDear Parent, If you cannot keep your child s appointment, we ask that you call us 72 hours (three days) before the appointment to reschedule.
Dear Parent, Thank you for choosing Emory-Children s Center. Your child s health is important to us, and we want to make your visit as easy as possible. To save time the day of your child s visit, review
More informationDavid A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX:
David A. Wang, MD Primary Care Sports Medicine Physician PRINT NAME: ADDRESS: DOB: AGE: SEX: SS# HOME: MOBILE PHONE: WORK: FAX: INSURANCE INFORMATION Did you injure yourself at work or is this injury a
More informationAutism Spectrum Disorder
Autism Spectrum Disorder Benefit information Premera Blue Cross (Premera) administers the Autism Spectrum Disorder (ASD) benefit for all eligible members. This unique benefit provides coverage for behavioral
More informationAnswers to questions that many parents ask about how the CAH program works. Helpful advice from other parents who have children in the CAH programs
Preface Care at Home: A Handbook for Parents is a guide that is intended to help parents/guardians meet some of the challenges of caring for a physically disabled child at home. It includes information
More informationPROTOCOLS FOR SPEECH THERAPY PROVIDERS
PROTOCOLS FOR SPEECH THERAPY PROVIDERS Type of Services Provided Services provided by Speech Therapy (or Speech Pathology) providers are covered for Santa Barbara Health Initiative (SBHI), San Luis Obispo
More informationKROME PROJECT - NUSOG OPEN ENROLLMENT 2014-2015
Open Enrollment for Benefit Plan Year 2014-2015 will begin Thursday, September 4, 2014 and run through Friday, September 12, 2014. Your new benefit plans and coverage begin on Wednesday, October 1, 2014.
More informationFacts About Dentists and Insurance
Welcome TO THE PRACTICE Patient Information Date Name Birthdate SS# Address City/State Zip Code Driver s License # Name of Employer Check appropriate box Minor Single Married Divorced Widowed Contact Numbers
More informationWayne Physical Medicine & Rehabilitation Associates 401 Hamburg Turnpike, Suite 105 Wayne, NJ 07470
PLEASE FILL OUT THIS SHEET COMPLETELY AND CORRECTLY. PLEASE PROVIDE ALL INSURANCE CARDS TO THE RECEPTIONIST TO COPY. Name Social Security # Address City, State & Zip Code Home Phone No. ( ) Cell Phone
More informationSummer Institute 2015 for CCS Students Arts Impact Middle School (Located on Ft. Hayes Campus) 680 Jack Gibbs Boulevard, Columbus, Ohio 43215
Summer Institute 2015 for CCS Students Arts Impact Middle School (Located on Ft. Hayes Campus) 680 Jack Gibbs Boulevard, Columbus, Ohio 43215 Columbus City Schools will offer the Summer Institute to assist
More informationBCSC Health Center Information
BCSC Health Center Information Welcome Packet BCSC Health Center 1950 Doctors Park Drive Suite C Columbus, IN 47203 Phone: 812.375.8810 Fax: 812.375.8879 Website: www.bcsc.k12.in.us/bcschealthcenter Frequently
More informationFamily Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT
Family Life Resource Center CLIENT CLINICIAN SERVICE AGREEMENT & INFORMED CONSENT Thank you for choosing Family Life Resource Center (FLRC) as your mental health provider. This document contains important
More informationSupplemental Coverage Option 2 + 1
Supplemental Coverage Option 2 + 1 Supplemental coverage gives you total health protection Our Blues Supplemental coverage fills in many of the Medicare gaps like deductible, and copayment amounts that
More informationCSHCN Services Program Prior Authorization Request for Inpatient Rehabilitation Admission Form and Instructions
CSHCN Services Program Prior Authorization Request for Inpatient Rehabilitation Admission Form and Instructions General Information Ensure the most recent version of the Prior Authorization Request for
More informationNichol A. Moses, Psy.D., NCSP
PATIENT INFORMATION SHEET It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to
More informationPatient Financial Policies
Patient Financial Policies Diabetes & Internal Medicine Associates, PLLC 2302 E. Terry St., Pocatello, ID 82301 208-235-5910 Fax 208-235-5920 Thank you for choosing Diabetes & Internal Medicine Associates,
More informationEssentials Rx 15 (HMO) Plan offered by PacificSource Medicare. Annual Notice of Changes for 2014
Essentials Rx 15 (HMO) Plan offered by PacificSource Medicare Annual Notice of Changes for 2014 You are currently enrolled as a member of Essentials Rx 15 (HMO) Plan. Next year, there will be some changes
More informationReferring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:
Patient Information Referred By: Referring Physician: Patient Name: Appointment Date: Time: Last First Middle Int. Date of Birth: SS#: Street Address: City/State/Zip: Phone Numbers: Home: Work: Cell: Email:
More informationPlease complete this form and return to the following address with any necessary documentation:
Please complete this form and return to the following address with any necessary documentation: Tamiko Burgess Phone 404-688- 9202, ext.12 Center for Black Women s Wellness Fax 404-880- 9435 477 Windsor
More informationTexas State PACE MAC Peer Mentor Job Description
Texas State PACE MAC Peer Mentor Job Description Peer Mentoring plays a crucial role in facilitating a successful First Year Experience for incoming Texas State students. The PACE Peer Mentor and Academic
More informationNortheastern University 2015 Medical Benefits
Northeastern University 2015 Medical Benefits Northeastern s 2015 Open Enrollment Effective Date: January 1, 2015 2015 Medical Plan Options Blue Choice New England Core POS Plan New Plan Blue Choice New
More informationPatient Registration Please Print Patient Name Last First Middle
Patient Registration Please Print Patient Name Last First Middle Address City Zip Home Phone Work Ext Cell Birthdate - - Social Security # - - Gender Marital Status Employer Referred by_emergency Contact
More information2015 Freedom Health Sales Presentation Video Transcript- (Host) (Member Testimony) H5427_15FHSalesPresVidv2_CMS Approved
2015 Freedom Health Sales Presentation Video Transcript- H5427_15FHSalesPresVidv2_CMS Approved Welcome to this presentation on Freedom Health s Medicare Advantage Plans. Today you will learn about the
More informationHigh Deductible and HSA Qualified Plans
High Deductible and HSA Qualified Plans For individuals and families HIGH DEDUCTIBLE PLANS Insuring Minnesota One Life At A Time w w w.preferredone.com Dear Prospective Members: Thank you for your interest
More informationCovered California Cost-sharing: What s the Difference Between Co-payment & Co-insurance?
Fact Sheet OCTOBER 2015 Covered California Cost-sharing: What s the Difference Between Co-payment & Co-insurance? Summary Even when you have insurance, understanding how much you have to pay when you go
More informationMedicare Solutions. Compare Medicare Supplement plans Learn how to enroll AZ1099. This is a solicitation for insurance 115555-15
Medicare Solutions 115555-15 Compare Medicare Supplement plans Learn how to enroll D12354 06/15 17791 0415 AZ1099 This is a solicitation for insurance Contact Customer Service or your licensed sales representative
More informationFrequently Asked Billing Questions
Frequently Asked Billing Questions How will I be billed? Mayo Clinic Health System will send you a billing statement with your charges. Provider charges for clinic and hospital services will be billed
More informationWelcome to Tri-State Rehab Services
Welcome to Tri-State Rehab Services Ashland Ironton Jackson Louisa New Boston Westmoreland Thank you for choosing our facility. To help us meet all your physical therapy needs, please fill out forms completely
More informationAnnual Notice of Changes for 2015
Cigna HealthSpring Premier (HMO POS) offered by Cigna HealthSpring Annual Notice of Changes for 2015 You are currently enrolled as a member of Cigna HealthSpring Premier (HMO POS). Next year, there will
More informationHEALTH INSURANCE TERMS TO KNOW
HEALTH INSURANCE TERMS TO KNOW Premiums A premium is a fixed dollar amount that will stay the same each month whether you use the doctor a lot or don t go to the doctor at all that month. It is what you
More informationHow to Use Your International Student Insurance Plan For the Students of. Presented by
How to Use Your International Student Insurance Plan For the Students of Presented by YOUR INSURANCE ID CARD Your ID cards will be sent to you after the start of Fall term (or Spring if you are newly enrolled).
More informationSelf Service Time Entry Time Only
Self Service Time Entry Time Only Introduction Welcome to this Self Service Time Entry session. This session is intended for employees that report hours worked, leave taken, and other payroll information
More informationWelcome to Back Country Physical Therapy, Intake Form
Welcome to Back Country Physical Therapy, Intake Form Patient Information: Name: Social Security #: Sex (Circle): M / F Address: City: State: Zip: Home Phone: Birth date: Age: Marital Status (Circle):
More informationINTRODUCTION EL CIVICS EMPLOYMENT UNIT Intermediate Level
INTRODUCTION EL CIVICS EMPLOYMENT UNIT Intermediate Level This guide will take you through the Employment 33 Objective. The objective is to: Identify and access employment and training resources needed
More informationSPEECH, LANGUAGE, HEARING BENEFITS
MAKING SENSE OF YOUR HEALTH INSURANCE PLAN SPEECH, LANGUAGE, HEARING BENEFITS Did you know? Hearing loss is the number one birth defect in the United States. Two out of every 10 children will have some
More informationBenefit Highlights. LifeWise Health Plan of Oregon MEDICARE SUPPLEMENT POLICIES. Discover a policy that s right for you. Effective JANUARY 2016
Effective JANUARY 2016 LifeWise Health Plan of Oregon MEDICARE SUPPLEMENT POLICIES Benefit Highlights Discover a policy that s right for you. Individual Medicare Supplement policies for residents of Oregon
More informationFAMILY PRACTICE PATIENT REGISTRATION FORM
FAMILY PRACTICE PATIENT REGISTRATION FORM **Today s Date: Clinic Name: Healthy Texan Pediatrics and Family Medicine PATIENT INFORMATION: (Please use full legal name, no nicknames) *Last Name: _ *First
More informationAvailable to Those who ARE Medicare Eligible
LACERA is proud to offer comprehensive medical plans to Los Angeles County retirees and their eligible dependents. Eligibility for some plans depends on whether the person being insured is eligible for
More informationFREQUENTLY ASKED QUESTIONS (FAQs) FOR MEDICAID CLIENTS. 1. What changes are proposed for the Medicaid Program in the State Fiscal Year 2012 budget?
FREQUENTLY ASKED QUESTIONS (FAQs) FOR MEDICAID CLIENTS 1. What changes are proposed for the Medicaid Program in the State Fiscal Year 2012 budget? Effective July 1, upon the adoption of the State Fiscal
More informationUnderstanding Your Medical Bills. Sinai Hospital of Baltimore. Rubin Institute for Advanced Orthopedics
Understanding Your Medical Bills at the Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore Rubin Institute for Advanced Orthopedics Rubin Institute for Advanced Orthopedics At the Rubin
More information